Two years after releasing the white paper, and six years since enactment of the HITECH Act, the question remains. There is inconclusive evidence that the program has achieved its goals of increasing efficiency, reducing costs, and improving the quality of care.

We have been candid about the key reason for the lackluster performance of this stimulus program: the lack of progress toward interoperability. Countless electronic health record vendors, hospital leaders, physicians, researchers, and thought leaders have told us time and again that interoperability is necessary to achieve the promise of a more efficient health system for patients, providers, and taxpayers.

We were pleased that the Office of the National Coordinator for Health Information Technology (ONC) recognizes the concern of hospitals, providers, patients, and other stakeholders, and recently released a draft roadmap for interoperability. In it, ONC proposes to work with stakeholders to develop minimal standards for the safe and secure exchange of EHRs. We appreciate ONC’s efforts to identify the steps necessary to achieve true interoperability of EHRs, but we are concerned that the draft speaks in generalities and does not address all of the concerns raised about interoperability in the REBOOT report.

The ONC roadmap provides a framework for responsibility, governance, and accountability in regard to the future development and implementation of interoperable EHRs. But instead of offering specific objectives, deadlines, and action items, ONC’s roadmap falls short on the nitty gritty technology specifics that vendors and providers need when developing IT products. We are left with many outstanding questions about how to achieve interoperability and how to address the cost, oversight, privacy, and sustainability of the meaningful use program.

Interoperability

A truly interoperable health system in local communities and across the country will enable physicians, hospitals, and other health care providers to seamlessly share patient information, such as medical histories or diagnostic tests, through a secure network. Sharing this information should improve care and reduce costs by allowing physicians to better coordinate care. For example, health information exchange between providers should prevent duplicative tests and harmful drug interactions.

After spending $28 billion so far of the $35 billion total taxpayer investment, significant progress toward interoperability has been elusive. Stage 1 of the meaningful use program failed to include any meaningful health information exchange requirements, and lacked a vision to achieve interoperability. Instead, Stage 1 incentivized the widespread adoption of EHR systems that providers now say are difficult to use and lack the ability to exchange information without costly upgrades.

We are now well into Stage 2 of the Meaningful Use program and providers are struggling to meet even modest health information exchange requirements. According to a report released by the Centers for Medicare and Medicaid Services (CMS) on February 10, 2015, only 131,905 out of more than 500,000—or roughly 25 percent—of eligible medical providers and hospitals had attested to either Stage 1 or Stage 2 for 2014. Responding to stakeholder feedback, CMS allowed more flexibility to providers to meet Stage 2 requirements.

By remaining in listening mode, ONC proposed high-level goals for how to achieve interoperability, like building on existing infrastructure and empowering individuals, but the roadmap fails to outline real and actionable next steps. It is not enough for ONC to identify factors it believes are important. It must also delineate how it will find specific solutions to these concerns. The HITECH Act was clear: ONC is supposed to certify EHRs that can meet the program requirements for the meaningful use of EHRs.

Meaningful use of EHRs is supposed to deliver value to patients and physicians, but instead we have reports that have shown that ONC certified products fail to deliver the value of easily exchangeable health information to better coordinate care. They are also incredibly expensive with no guarantee that providers purchasing certified products will achieve the Meaningful Use program requirements.

Indeed, through the ONC certification program, ONC has had the ability to achieve interoperability, but instead ONC is still struggling. Nothing makes this point more clear than this fact: Stage 2 meaningful use was promised to be the stage when health providers were interoperable yet we are well into Stage 2 and ONC is just now releasing its vision for interoperability with a high level roadmap.

We have seen many high-level documents on interoperability: the JASON reports, the Health IT Policy and Standards Committees’ reports, the Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure report, and the Federal Health IT Strategic Plan 2015-2020 report. All of these reports, as well as the ONC’s latest roadmap, are missing the same thing: practical and actionable steps to ensure a proper return on the American people’s investment.

Increasing Costs

In 2009, the Congressional Budget Office (CBO) estimated that fully integrated interoperability would save the Medicaid and Medicare programs $12.5 billion through 2019. These savings have yet to materialize and with 50 percent of doctors unable to meet current program requirements, it is unlikely that taxpayers will see these savings in the near future. Moreover, the number one complaint we hear from providers is the unexpected costs of maintaining and upgrading their systems.

ONC does not describe how it will determine the costs associated with the adoption of expanding interoperable platforms. Nor does ONC explain how it would evaluate cost or incorporate cost control into the development and scaling of interoperability. Provider concerns about the cost of complying with the program should be addressed in the roadmap.

We appreciate the notion that as new models of care begin to reward providers for outcomes, changing incentives will reward interoperability. We agree. However, we live in the aftermath of the HITECH Act, where to date $28 billion have not resulted in significant improvements to clinical care coordination or quality. Without concrete immediate and long-term steps, tied into accurate, usable (and collectable) performance measures, we will continue to see a meager return on investment.

Lack of Oversight

One way to improve oversight of the program is to put in place measures to gauge success. ONC appears to be taking a step in the right direction by describing seven different lenses to measure and evaluate the quantity and quality of information flow within interoperable systems, such as who is exchanging information, and where and what type of information is being exchanged. However, without specific performance goals for each type of measurement, it is unclear how ONC will measure success. In addition to defining these metrics, effective oversight includes describing how the metrics will be collected, analyzed, reported, and used for decision making.

The fiscal year 2015 Omnibus Appropriations Act required ONC to issue a report on information blocking — the practice that EHR vendors, and sometimes hospitals and physicians, use to prevent electronic information exchange as a way to gain a competitive advantage in the health care marketplace. The report will give Congress a better understanding of the extent to which information blocking happens and a comprehensive strategy on how to address it. It will also provide a good example of how ONC exercises its oversight responsibility.

Patient Privacy at Risk

The security of patients’ personal health information in EHR systems is a real and immediate concern to us. According to a warning the Federal Bureau of Investigation (FBI) issued to health care providers in April 2014, the health care industry has the highest volume of cyber threats and the slowest response time. The industry “is not as resilient to cyber intrusions compared to the financial and retail sectors, therefore the possibility of increased cyber intrusions is likely,” the FBI stated. Unlike a credit card number, the information contained in a patient’s health record is impossible to reissue. Health records contain financial records, personal information, medical history, and family contacts — enough information to steal and build a full identity or use for valuable research purposes.

The ONC roadmap describes collaboration across several government agencies to accomplish their security goals. It says the Department of Health and Human Services will work with the Office of Civil Rights and industry to develop and propose a uniform approach to developing and enforcing cybersecurity in health care in concert with enforcement of HIPAA Rules.

However, the roadmap lacks clear, obtainable goals regarding security requirements and implementation. Additionally, the costs for our future security infrastructure are unknown, as well as who will pay for it. As new cyber threats emerge every day, this administration must answer these questions quickly. The recent hack on a major health insurer that compromised personal information, including Social Security numbers and health histories, of tens of millions of Americans highlights the urgent need for an appropriate framework to protect patient privacy.

Program Sustainability

The long-term sustainability of EHR systems remains one of the biggest unknowns. ONC’s roadmap is surprisingly silent on this topic, which is stunning considering that there is only $7 billion in funding left from the HITECH Act. While the President’s Budget does request a significant increase in funding for ONC, the administration seems to ignore the reality that taxpayers have already committed billions of dollars toward a goal that is still vague.

According to ONC, implementing EHR systems range from $15,000 to $70,000 per provider. According to a September 2014 IBIS World Report on EHRs, nearly 45 percent of physicians from the national survey reported spending more than $100,000 on a system. About 77 percent of the largest practices spent nearly $200,000 on their systems. However, even these estimates fail to consider upgrade and vendor costs associated with running these systems. Numerous stakeholders have stated that one large obstacle to interoperability and sustainability is the cost of sharing data among different vendors.

ONC envisioned the State Health Information Exchange Program would help facilitate this exchange, and taxpayers spent over $500 million on this effort. Yet, the program has failed to provide a long-term approach to information exchange. According to a RAND Study published in December 2014, only about 25 percent of the nation’s health information exchanges are considered financially stable by those who run them. These programs’ inability to sustain operations without federal funding triggers more questions. With HITECH Act funding dwindling, we fear that time is running out for ONC to make meaningful advancements toward interoperability.

Looking Ahead

In listening to the concerns from EHR vendors and EHR users from across the care continuum, ONC has taken an important turn under the leadership of Dr. Karen DeSalvo. The previous ONC leadership did not understand the difficulty and enormity of creating government-approved products in a market that struggled to exist before government incentives arrived.

As a result, our nation’s health care providers are stuck with the huge cost of unwieldy systems trying to conform to government mandates. They are stuck adopting EHR systems which don’t fit into their established workflows. And if they actually want to share their patients’ data, they are stuck with even more costs imposed by vendors.

At the center of all this is the patient who must sit quietly in the exam room looking at her physician use a computer instead of directly talking with her, who likely has seen no better access to her own data, and who is struggling to understand why her doctor has such a difficult time getting her lab results.

That the ONC roadmap recognizes these concerns is a welcome change. High-level ideas are important, but we are concerned that without specific requirements and action items, we will not advance towards the goal of improving health care coordination and patient care, which was the intent of the HITECH Act.

As long as patients / consumers and licensed physicians have no market power to drive interoperability, $35 B or the next $35 B will not be enough. Through Stage 2, Meaningful Use has simply amplified a market failure by giving the largest institutions and the largest vendors to those institutions a license to lock-in patients and physicians. Expecting costs to go down or market forces to drive competition when the consumers and the prescribers have no market power is illogical.

HIPAA already gives patients a “right of access”. The JASON Public API is a reasonable definition of a policy-neutral interoperability technology. What ONC and / or Congress need to do is to equate the “patient’s right of access” with “the patient’s right to authorize their own information flow on the Public API.”

A patient-directed approach is the only logical way to bring market forces to bear on interoperability. It’s not too late for Stage 3 to adopt this focus (as the JASON Task Force clearly stated) but if not, then Congress would do well to act.

The issues raised by the five senators is absolutely right on. Not only is the ONC document light on specifics, there is reluctance to open up the problem for others to solve. There is no question this is a challenging problem, but like so many other, high-tech sectors, it is not an insurmountable problem. It is a problem that has been solved already in other tech sectors, and a solution exists within healthcare.

The problem of interoperability, and by extension, the real-time, actionable use of patient health data for the clinical management of acute and chronic illness, will not come from EHR vendors. Although with regulations, policy and customer pressure, EHR platforms can become more collaborative in nature, it is not likely a single piece of software can focus both on the requirement of patients and healthcare providers as well as address the needs of communication and data sharing in healthcare. We need to look elsewhere.

As a physician, I share many of the frustrations other providers describe with EHR technology. Our concern is the way they have been designed to allow for safe and effective access to patient data along with efficient data entry, and capturing the meaning healthcare providers bring to the care, and understanding the complex and massive amount of data being generated.

We can and must redesign how we use the data in healthcare. Not only has healthcare reform shined light on the need for understanding the massive data sets currently being collected on populations of patients, it has also brought attention to the real possibility of personalized medicine customized for each one of our patients.

Physicians and other healthcare providers have become very concerned about the use of access to, and worst of all, the high potential of missing critical pieces of patient information that is buried in the many layers and multiple, often inconsistent screens present in all of the EHR’s. We need to think beyond enterprise software applications into how we can develop better views, smarter documents, and visualization that brings safety, clarity, usability and value to the patients we are caring for.

Middleware allows for the connecting of current, disparate EHR’s so the data can be collated and viewed in a more standard, or even customized manner for specific specialty workflows or care needs. It can also re-engineer the communication system of healthcare, something that has not been innovated since the introduction of the pager.

Communication no longer needs to be a manual, interruptible process. Given the care-team model of healthcare delivery across a care continuum, we need to think about who is responding to the needs of our patients and how these responses are communicated to the rest of the team. This technology has been developed. I have worked directly with the platform developed to address these needs and in a way to support and augment providers workflows.

Please help bring change to the way we interact with and develop applications that support the needs of clinicians and our patients, and allow for the emerging technology that is quickly reaching clinical medicine. Solutions do exist, but they are not being explored to support the tenants of health reform, the needs and demands of providers, and to enhance patient understanding of their care while engaging them into becoming active participants. This is not a criticism of EHR vendors, but instead a plea to look at the problem from another, more innovative way.

Opening things up to this will bring great value to all involved, including the EHR vendors themselves.

Many of the points regarding interoperability (or lack thereof) are well taken. The federal government’s approach to interoperability over the past 10 years has been energetic and well-intentioned, but (IMHO) fundamentally flawed in its omission of certain key project-management and engineering principles. I’ve discussed these in some detail in the opinion piece “Interoperability: Failure to Launch” (http://www.ihealthbeat.org/perspectives/2015/interoperability-failure-to-launch), but the bottom line is that interoperability goals have been too vague, technical leadership too diffuse, and real-world testing too cursory or entirely absent. I believe it’s not too late to remedy these issues and apply more effective processes, but it requires a willingness to invest sufficient time, as well as an acknowledgement that the approach of the past hasn’t worked and cannot work.

What I find particularly interesting is how people define Interoperability. Many people think it’s all about document exchange, but that’s simply an enabling technology, not the end game.

Let’s say we can all exchange documents by querying against Commonwell, or CareQuality, or even by using Direct. How does the physician incorporate that data into their workflow taking into account data provenance?

Not all data is accurate or even relevant. So, should the data be pushed into the EMR, or queried at time of service? How will information be curated?

ONC says “ ‘[details] should be handled through the industry-led process that we called for in the roadmap’ and ‘we think industry should be on the hook to carry out a collaborative process where they make decisions about detailed implementation pieces,’ “ Really?

We have been jerked around by interoperability ever since (and probably before) former HHS Secretary Leavitt defined it as, basically, whatever HHS says it is (think Alice in Wonderland). There have been panels, committees, task forces, conferences, roadmaps, workgroups, blah blah blah. Billions of dollars squandered, courtesy of HITECH.

Distribute a version of VistA, the VA EHR, at nominal cost, and license it so as to optimize innovation by end-users, i.e., physicians, nurses, hospitals, and the problem of interoperability (along with many others, such as usability, patient safety, privacy) will be solved sooner than anyone thinks, so long as there is widespread adoption. The proprietary vendors will come to heel, or become irrelevant.

I suggest that, when the March 5 meeting is reconvened, the Senate Committee on Health, Education, Labor and Pensions include requested testimony from DoD, OSEHRA, ONC, and organized medicine, perhaps the AMA and/or AAFP.

The fundamental problem is that health care as an industry has always used legacy technologies. Large vendors and consultants have colluded to keep these software written using arcane languages like Mumps remain in production. The largest and the most expensive EMR on the market uses Mumps. The Vista system used at the VA is based on Mumps. They have a closed architecture, meaning information cannot go in or come out freely. To have “industry” led certification processes made it easy to “certify” such applications that cannot meet the basics of inter-operability. Why complain about interoperability now? These software packages should never have been certified in the first place. Open architecture should have been a prerequisite and every application must be required to make their data available in common readable format – like excel or cvs. That’ll solve the problem immediately.

I read the entire REBOOT report. It is well done. And yet, why oh why has no one mentioned the players in the IT industry as being a very big part of the problem? For the most part, the healthcare industry sector was late in adopting IT in any dimension. This means that the healthcare industry could have, and should have, benefited enormously from the decades of work already accomplished by the IT industry and the other large economic sectors that had adopted IT between 1980 – 2000. This is especially the case regarding the holy grail of interoperability.

IT has known how to design and create interoperable systems for quite some time (likely due to other massive taxpayer-funded government initiatives where interop was mandated to IT).

IT has been salivating when looking toward their last market (in the USA) for massive revenues, i.e., healthcare. IT has known all the “trip-wires” in the rollout of complete and interoperable systems for decades. It is in the financial interests of IT to let inexperienced executives and MDs in healthcare (whose proper focus is on … health) make uninformed decisions, comply with too many complex requirements, and take the financial hit when they cannot meet meaningful use criteria of IT generated products/services.

2000+ Vendors …. on the receiving end of taxpayer dollars, as these monies pass through the uninformed in healthcare?? In IT we called this “low-hanging fruit.” The healthcare industry is culpable, but IT has been aware all along of the windfall coming their way.

Analysis and oversight should also be just as laser-focused on the promises made by IT vendors as it now being focused on healthcare players, from CMS to small MD provider offices. And this analysis, if done, will find a disturbing level of conflicting interests among all involved.

So much for Health Affairs’ often vaunted “objectivity.” To publish a partisan article of this sort with no opportunity on the part of ONC or the CMS to respond is depressing. Just as a reminder–during the previous administration we relied on jawboning the private sector to do the right thing with regard to HIT and the result was precisely nothing. That would have continued to be the result of such a strategy indefinitely. Only a “top down” intervention was ever going to change the conversation.

Absent the HITECH provisions of the ARRA back in 2009, we’d still be bemoaning the fact that only 20%-30% of providers were generating digital data. While “Meaningful Use” hasn’t been perfect, it has at least accomplished the laudable goal of getting doctors and hospitals to begin the long process of automating clinical data capture. It’s easy to sit on the sidelines and criticize the flaws in the program. It’s much tougher to present a viable alternative. Let me respectfully suggest that the authors be challenged to present a fact-based alternative program that would have accomplished as much in as short a time, and at as low a cost as “Meaningful Use.”

Maybe because IT is not the magic secret to reducing health care spending?

What has been shown to reduce health care spending? Primary care.

Why is there an inadequate supply of primary care? Because PCPs are paid half of other doctors, and they get more grief from insurance companies, including Medicare.

Why do Medicare and other insurance companies pay PCPs half of other doctors? Because over the last 65 years, other specialties have been paid more and more.

Why have other specialties been paid more and more? Because insurances, including Medicare, have been paying other specialties more and more.

Why have insurances, including Medicare, been paying other specialties more and more? Because of UCR.

Why does UCR set prices for primary care services so low? Because insurances, including Medicare, have been paying other specialties more and more.

Why have insurances, including Medicare, been paying other specialties more and more? Because of UCR.

Why does UCR set prices for primary care services so low? Because insurances, including Medicare, have been paying other specialties more and more.

Why have insurances, including Medicare, been paying other specialties more and more? Because of UCR.

Why does UCR set prices for primary care services so low? Because insurances, including Medicare, have been paying other specialties more and more.

Why is there an inadequate supply of primary care? Because paying for primary care under UCR/FFS doesn’t pay for the value primary care brings to the system.

What’s one part of the solution? Allow PCPs to opt out of FFS for Medicare, pay them a monthly fee (~$100 PMPM, more for people with multiple morbidities) for Medicare patients. We know just adding more primary care to the system reduces costs. By eliminating the enormous wasted expense of billing ($85k/MD in a large multispecialty office, but it’s proportionately much more for primary care,) PCPs avoid that expense, taking home more even with the same overall payment from Medicare. Paying for the value of primary care would increase the supply of PCPs. With a greater supply of primary care, we can start to address other problems in the system, but we can’t do any of them without an adequate supply of primary care.

This is very well stated.
Working docs are indeed frustrated indeed,by endless computer glitches check boxes, templates, 5 clicks to e prescribe when 1 or 2 would have been legible and checked for interactions IF we could still fax it( but then the vendors lose eh?) type of issues.EMRs raise costs to us that we cannot pass along.
Add to that the miserable pay that we get in primary care after convoluted coding and billing rules
My understanding may b e limited compared to the high level reports the authors have seen- but my understanding is that interoperability is not easily achievable. We could instead post to a common site..

I strongly suggest that Dr Disalvo get a real working doc as an advisor..
signed- yes real working doc solo fp with high function glow cost practice

Most of the data shared is local. My local hospital and my office notes should be interchangable (they are not curently, and I work for a hospital based group). In this journal last month HHS put foreward their 5 yr plan and it is still collect data then think about sharing data and eventually (the next 5 yr plan) find uses for the data. If you Senators are waiting for the folks at HHS to do something don’t hold your breath.

During the ACA debate on CSPAN Sen. Coburn from Oklahoma proposed to suspend Stark rules and let any hospital extend for free or a reduced fee an office EMR as an extension of the hospital into the physician offices. This would allow easy exchange of data. It would benifit the patients and help defer the cost for physicians. In cities with multiple compeeting hospitals there may be some issues. But most small community hospitals across the country it could solve alot of problems.

March 4th, 2015 at 3:39 pm

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